Sid Meier's Hospital

So I'm on Plastic Surgery this month. Excuse me, Plastic & RECONSTRUCTIVE Surgery. Though I think it's fair to say the department here earns that title as they do a fair bit of reconstruction amongst the stripperplasties and wrinkles-be-gonesies. It's strange being back on an academic surgical service after a break of over 3 months, but refreshing at the same time as the duties of the medical student on said services of academia (list updating, prerounding, hastily presenting, obscure pimping) are warm and familiar to me. Like a well worn sweatshirt or something. But the hours still suck.

We had a really interesting person on the census the past while - the whole package, interesting medical case and interesting personality. The guy was tackled by a buddy of his and broke a rib. Being the regular dust-on-the-boots American that he is, he didn't come to the ED but rather was just going to deal with the pain. Problem was, he was a nice guy, and since bad things only happen to nice guys, the rib pierced his pleura and soon enough he was in the hospital whether he liked it or not with a rip roaring empyema. One lobectomy, a lat flap, and a couple chest tubes later, he found himself parked on the floor slowly biding his time until he was given the blessings of the great doctors to go home. The healing was slow and he was nearing 2 months on service when I rotated on.

Of course he felt well enough, and rather than bore himself with watching his chest tube output, every day when we rolled through the room in the clusterfuck that is surgery rounds, he would be clicking away on his laptop, engrossed in a computer game. Now despite my rugged and masculine exterior, I am quite the computer nerd. Growing up in the glory days of DOS, I spent many an hour of my youth tinkering away at the computer keyboard with classics such as X-Wing, Doom, and Mechwarrior. Like like many things of youth, these hobbies have slowly been eroded away by the responsibilities of growing up. So on rounds we were much more focused on said chest tubes than what was on the computer screen.

Finally, after a few days on service, the chief resident glances up from the patient's incision and asks "Are you playing Civilization???"

The junior looks up from the chart to add "Hey, I love Civilization."

Intern: "What version? I haven't played 5 yet."

From my n=1 experience, I can now say that all medical students and residents have played Civilization. I'm not sure what that says about our demographic, but the computer nerd in me grinned internally.

Sure enough, this past weekend we were rounding with the attending on call, and our fearless world leader slash conquerer was getting ready to be discharged home. We roll into the room and there he is, clicking away at his laptop like always. He's excited to go home. We make small talk. Finally, the attending was bent over glancing at the site of the last chest tube, when she comments "Is that Civilization? I love that game!"

Somewhere, Sid Meier is smiling.

Livin' in a woman's world.

So I'm a week into OB/Gyn, which has traditionally been labeled as the estrogen-charged girls club of the third year rotations. I've heard some horror stories from a few members of my class of the male gender, so I had a few trepidations heading into the rotation.

I was standing in the workroom doing board rounds last week when the conversation of the room turned to hair straighteners. Believe me when I tell you I now know more about hair straighteners than I ever cared to know. My intern turned to me and mouths "sor-ry", and someone makes a comment about how I was the only guy in a room of 9 women. The funny thing is, I didn't even bat an eye at the entire situation. Hell, I didn't even notice the female predominance of the room until someone pointed it out. It seems like I've been working on female dominated teams more of the year, so I decided to do a formal count.

And of the 40 residents and attendings I've worked under this year... 33 have been women.

Maybe this has conferred some inherent advantage on this rotation, because things have gone swimmingly well so far. After all, we're all just living in a woman's world.

4 weeks left in third year.

Character approved.

So one of the fun things of this rural rotation is that I get to know a lot of the docs in the hospital, just by virtue of its small size (40 beds). I've been scrubbing a couple cases with "the" general surgeon on staff who's a real character. Pushing 70 years old, 5 ft and change, originally from Brooklyn. Which means he's a little ADD, a little senile, lacks any sort of social filter, and is a helluva surgeon. Kinda like Tommy DeVito from Goodfellas, except Jewish, and minus the mean streak.

Example of an exchange we had:

"So its my 40th wedding anniversary this weekend"
"Congratulations! That's quite the accomplishment! Any big plans?"
"Well, it's actually our 39th. But I'm telling the wife its the 40th so I can take her to Switzerland at the end of the month. That way we get to do it twice. The broad doesn't have a fuckin' clue how long its been, but god do I love 'er."
"Haha, that's brilliant."

Anyways, earlier this week I scrubbed on a "soft tissue mass excision", which was basically excising an abscess. The thing had been I&D'd a couple times and always recurred, and since it sat squarely in the patient's perineum (3 cm or so lateral to the anal triangle, almost right over his ischial tuberosity... yeowch), it was a painful sucker.

So we're about to start the case and Dr. DeVito turns to me and says "I was gonna let you cut, but I'm gonna try to get this sucker out without piercing the abscess. Y'know, keep the pus out of the wound and we might be able to close him up and save him a lot of trouble." We get the site draped, eyeball/palpate the abscess, and draw a nice clear margin on the skin. I'm ready with suction in hand, Dr. DeVito makes the first cut, and... almost immediately pus pours out of the incision all over the surgical site, sprung free from a pocket of the abscess that was tracking laterally under the skin.

"Well, shit. Might as well let you take over."

He turns, hands me the 10 blade, and grins.

ADD stands for Attention Deficit.. LET'S GO RIDE BIKES!

Well that was fun while it lasted. I was really in a groove there for a while, but alas, no good thing in medicine lasts long. I'm going into my 9th week of internal medicine now... and I'm sick of it. Sick of detailed assessments and plans, sick of "rule out MI", sick of pontificating on the various minutiae of pathophysiology. Granted 9 weeks in any discipline can get tiresome, I imagine. Couple that with being sorely behind in my review for the massive "you will FAIL this shelf!" shelf exam bearing down in 11 days, and a new senior who believes "you can't learn if you aren't in the hospital, so I'm going to keep you here forever muahahaha" and well, you get the idea.

But if there's one thing you learn as a third year, its how to grin and bear it.

11 more days.

Grin.

In the meantime, if you're looking for some good reading, don't look here. But look here:
Great story about the hidden lives of our patients, by Aggravated DocSurg. This story really encapsulates where I was at with my last post.

If you're a pre-med or just someone considering going to medical school, don't do it for the money, or the so-called "prestige", or the babes, because such things are slowly being eroded away (well, except the babes... I think?). But there are still plenty of great reasons to go into medicine, and Dr. Parks over at Buckeye Surgeon states it absolutely eloquently.

And, and your homework for next time... read up on Throckmorton's Sign.

'Till next time.

Respect Mah Authoritah

Wow, has it really been a month since I've posted? Apologies, my loyal reader(s) (hi mom!). I successfully survived my family medicine clerkship and sat through long hours of lecture during our "continuity curriculum" week (sidenote: how in the hell did I ever survive the first two years of medical school? I can barely sit and listen to a presentation for an hour now; I can't believe I used to do it for 4-8 hours straight every day).

Which brings me to my current location within the lands of an "Elective Block". Unlike some of my classmates who decided to do something clinical with that time, I decided to pursue a research elective, which I have concluded (as I sit in Starbucks and sip on my delicious holiday drink) was quite possibly the most awesome decision I've made this year.

The original plan was to have one study I was going to pound out in this 4-6 week period. Well, that 1 study turned into 2, and the 2 turned into 3 (well, more 2 1/2) and suddenly I am growing research protocols out of my ears and dreaming of HIPAA waivers of authorization. Yet despite all the madness, the simple fact that I get to set my own schedule has been incredibly refreshing. No sitting around in the afternoons on the wards bored out of my mind, no scut work, no asking permission to leave, no early mornings unless I am feeling particularly motivated. Ahhhhhh.

There is one thing that has been particularly maddening though; it's $%#@$%ing impossible to get anyone to do something for you if you're "only" a "medical student." It's the sad reality of the authority purgatory we reside in. On the wards, we can make treatment recommendations but can't prescribe medications. We can place orders but they have to be co-signed. Our notes are part of the medical record but residents must write separate notes for billing purposes. Because there is so little we can actually accomplish independently, we exist in this strange limbo where we can do a lot but there's very little we can actually "do." So it's understandable that there tends to be this dismissive attitude towards med students in the hospital, and I'm cool with that. But the reverse is also true - it often seems impossible to get anyone to do anything for you as a med student. On the wards, I've learned to stop signing my pages with "MS3" because if I do it'll be over an hour until I get a call back. I always go back to a moment on my psych rotation when one of my fellow students on the team slammed down the phone and yelled "Do they REALLY think its only the med student who wants this CT? Just for sh*ts and giggles?!? I'm CALLING because my ATTENDING wants the damn CT scan! RESPECT MAH AUTHORITAH!"
Yup, been there before.
Well, I've found that the research realm is not exempt from this phenomenon. Every email I send needs at least one follow-up before I get an answer. Every voicemail I leave requires at least one call-back before I get a reply. Being that I have precious few weeks where I can devote all my focus and time to this, I'm trying to get things done in an expedient manner, but too often it's like trying to work in quicksand where every action requires twice the normal effort. It's almost a daily occurrence where I want to have a cow and just yell "I'm CALLING because my PI wants the damn form signed!"

So, if there is anyone from the IRB reading this: Please. If a medical student is asking for help in getting something done, try to help the first time. We are not rogue anarchists set loose in the hospital to do what we want all willy nilly. If we're trying to get something done, there's typically a damn good reason why we are.

Now, back to my delicious holiday drink.

Hula Hoops

Jumping through hoops is a familiar feeling for any medical student. After all, it's something we have been doing at every level of our education. High school had its own set of hoops, filling college applications with National Honor Society merits, projects, AP classes, and the ilk. When time came to apply to medical school, there was a whole new set of hoops to tackle. Dean's lists, president's lists, scholarships, shadowing experience, personal statements, activities lists. Many experience a sense of relief on the arrival of that medical school acceptance letter. A feeling that you're finally reached the upper echelon of your training and the jumping of hoops is finished.

But alas, medical school brings its own new set of hoops. Anatomy, physiology, pathology. Step 1 and Step 2. Networking, schmoozing, research, clerkship grades. Once again, I will be pounding my head against a keyboard attempting to coherently produce a personal statement within the coming months. With my decision buck up and shoot for an ENT residency, the theme of the past month has most definitely been one of hoop jumping. I've been (somewhat) frantically trying to throw things together for a research elective coming up in November/December. Working on trying to network and get some clinical and OR experience in the process. Basically filling up my free time afforded to me by psych with numerous small projects all to play the game. Who wants to be bored anyways?

I tell myself this is the last time, but know that's just a personal delusion. But hey, I hear hula hooping is a great core workout.

New content... but not here

As I mentioned before, I'm going to be guest authoring over at headmirror.com with articles talking about my experiences pursuing an ENT residency, and hopefully offering some good advice and useful information along the way. Sort of like Dear Abby, but without the botox or perm.

Anyways, my first post is up. You can check it out here (navigate to the Medical Students section), if you're feeling whimsical.

And now... a picture of a kitten.

Balls.

So during our pre-clinical years we had this wonderful class called "Principles of Clinical Medicine" which was "designed" to impart onto us all the skills we need to survive in the clinical world that you don't learn out of a basic science textbook. We had lectures on giving bad news. Lectures on disaster preparedness. Lectures on healthcare reform. Lectures on "adapting to a chronic illness." The culmination of the class was something called the (Group) Objective Standardized Clinical Examination (GOSCE if as a group, OSCE if solo), where you had to perform a history/physical exam on fake patients often with one of the "difficult" issues lectured on, such as substance abuse, non-compliance, divulging a medical error, etc and graded in checkbox style on whether you washed your hands, shed appropriate tears, preserved modesty whilst sticking a finger up a man's inguinal canal, and such. Did it help me prepare for my clinical years? Yeah, I think so. But as far as preparing me for what I do 75% of my day, it didn't help squat. So instead, in order to better prepare MS1s and MS2s for what the wards are actually like, I propose the OSCE be replaced with... the SACK (Subjectively Arbitrary Clinical Klusterf*ck - with a K 'cause SACK is a way cooler acronym than SACC)

Here is how it would be conducted. 10 students would be unleashed into a mock ward with 1 patient assigned to each of them. There is a workroom with computers. The student must:
(1) Log onto the records system on a computer terminal to read up on the full H&P, course, vitals, labs, and imaging of their patient and commit them in some form to memory
(2) Go see their patient and get overnight updates/perform a physical exam
(3) Go talk to the nurse for the patient to find out what really happened overnight
(4) Come back to computer terminal and write a progress note complete with assessment and plan with a "well thought out and thorough" differential and relatively accurate plan
Now the rules of the exam:
--The student must perform all of the above tasks on a timer of 120 minutes. At the end of the 120 minutes, the student must present their patient while individuals in long white coats stand around, shuffle their feet, and clear their throats
--Even though there are 10 students and 10 patients, there are 8 computers in the work room. Additionally, throughout the course of the 60 minutes, 8 individuals in long coats representing consults, attendings, and residents will come in and sit at terminals to check their google mail and book airline tickets to exotic tropical places. The students have no choice but to defer to hierarchy and rescind a computer terminal if needed by said individuals. Said individuals can sit at any station as long as they want, and if all 8 individuals decide to use computers, students have no choice but to stand there wasting precious time
--There will be 5 nurses for the 10 patients. At any moment 2 of the 5 nurses will be missing and no one knows where they are.
--60 minutes into the exam, the students will all be herded into a room and forced to listen to "morning report" for 30 minutes, denying them access to patient, work room, or computer terminal and cutting their effective work time down to 90 minutes
--Patients will either be too tired to give a good history of last nights events or physical exam, too cranky to give a good history of last nights events or physical exam, or too drugged to give a good history of last nights events or physical exam.
--You are allowed to print your notes for aid in your presentation at the end, but only 2 of the 8 computers will send to the printer

Now that's real wards experience.

BTW... saw my first code today. A parent of a patient seized and collapsed in the hallway right outside our workroom. He hit his head on a counter, cracked his skull open, and went apneic. I stayed out of the way, since simply observing the carts and the medical supplies and the pooled blood on the floor was way too much for me. But good lord, within minutes of the code being called there were 50 docs and nurses all in that narrow little hallway while people tried to get supplies and a stretcher to the patient. It was like pigeons at a bird feed sale.

Cryptococcus!
(You might be a med student if you get that joke.)

So you want to go to med school, huh?

Well, to survive the first two years, all you need to do is memorize this information in 74 weeks:


5 wood and manatee for comparison. Manatee may or may not be to scale. Tape measure reads just over 4 feet tall (1.21 meters) tall.

Done with second year. Wooo.

An Apple A Day Keeps The Doctor Away

Back when I was younger, I used to hold a certain level of disdain for people who owned Apple electronics. Too trendy for me. Not enough functionality for the price.

Fast forward 5 years. I'm in a Starbucks, doing QBank questions on my MacBook Pro, listening to Explosions In The Sky on my iPod, my gym equipment with my iPod Nano in my car. I get a text message and respond... on my iPhone.

My how the mighty have fallen.

A fairwell to Scrubs.

A couple years ago, when I was recovering from a shoulder surgery, I watched every single episode of Scrubs in chronological order. Yes, I'm that big of a Scrubs geek.

So it was sad to see the show end last night after 8 seasons on the air. I always insisted it was the most accurate medical show on TV, and people often stared at me with crazy eyes for suggesting a slapstick comedy show could do such a thing. But I still feel like no other show really got at the deeper drama and emotional aspect of a hospital than Scrubs did. And its medical terminology was always spot on.

So farewell, Scrubs. And thanks-for-everything-five.


And yes, I can finally tell after all these years that the xray is backwards. Either that or the joke is on us and we're looking at a perfect example of situs inversus.

Want some cheese with that swine?

So yeah, pigs are taking over the world. Or at least the news feeds and the stock options for Prestige Ameritech and their surgical masks. Everyone's heard about this swine flu deal which frankly strikes me as a cross between Y2K and the bird flu scare. But science will not be deterred! Science will overcome! Science will... uhmmm... compose?

Some dude, Stephan Zielinski (I knew a Stephan and a Zielinski in high school, wonder if they married) transcribed the amino acid sequence for hemagglutinin 1 (aka the "H1" of H1N1 influenza) into a music sequence. In his own words:

"Each beat corresponds to one amino acid, and the piece is in 3/4 time, so each six measures would correspond to five turns around the alpha structure. (I’m weaseling because I haven’t the foggiest idea how the protein actually gets folded.) Amino acids with side chains that are neither aromatic not aliphatic control the piano and organ: the nine non-hydrophobics the piano, and the four hydrophobics the organ. The three amino acids with aliphatic side chains control the low synthesizer, while the four with aromatics control the percussion."

LISTEN TO IT HERE

It's strangely beautiful, in a child-with-Lennox-Gastaut-playing-your-keyboard-from-the-early-90's sort of way.

Christmas... Break?

Turns out the winter storm referenced in my previous post was simply a little foreplay from Mother Nature until she unleashed the full-on kama sutra of arctic chill on my little niche of the world (see right). As a result, I abandoned Siberia, I mean, my apartment, and have been sleeping on various couches of various houses I have broken into over the past 10 days. Having no internet access for nearly 2 weeks, being sans car, sans bed, and sans normalcy has been equal parts entertaining and maddening. The Great Thaw has finally come, and with it my migration home, just in time for me to hop on a plane tomorrow for Vegas and New Years. I don't really know what the point of this post is except to justify my hiatus. I was hoping to post some thoughts over break but that will have to come after my return from Sin City and the hangover subsides.

Until then - Vegas, baby. Vegas!

MedZag gets beatdown by Old Man Winter.

oh hai. Apologies for going on hiatus for two weeks. Haven't had much to post for the last while, but we've currently been slammed with a nice winter storm the past two days which has effectively put me on house arrest. For those of you who have no idea where I go to med school... that pinpoints my location down to pretty much 30 of the 50 states. For those of you who know where I go to med school... you know what I'm talking about. We actually got a snow day yesterday, which I never thought I'd see in med school.

You know, in med school we like to talk about all the things we gain in our training. Experience, knowledge, insight, competency, warm fuzzies, giant egos, all that shmooze. But I also have been reflecting lately on the things I've lost in med school. No, not my virginity, or my sense of humor (completely). But I have lost a great deal of patience (thankfully no patients yet). Not to toot my own flute, but I used to be a pretty darn patient person in my younger life. But one of the constants in medicine is the feeling that there is never enough hours in a day. And I've been deluged with that feeling every day for a while now. Between trying to keep up on studying, trying to maintain my sanity, trying to make it to meetings and talks I find interesting, and trying to maintain a semblance of a six pack, I find it amazing I have found time to even poop or sleep. Lately I've noticed myself become exasperated by activities, PBL sessions, and lectures which I feel like are a waste of time. I haven't developed overt road rage yet, but have formed a habit of yelling expletives at slow drivers (which breed like rabbits in this state) in front of me regularly when driving alone.

But it all came to a head this week. Now normally I have quite the active routine. I go to the gym, go study at different coffee shops, basically get away from my apartment, which is too close to campus and frankly claustrophobic.

Damn you freezing temperatures. I've been stuck at home for only 2 days now, and have already resorted to cleaning my apartment (!), organizing my DVDs, and even studying at home, a near impossibility for me normally. I am going insane.

Speaking of studying, we're currently mucking through endocrinology, which I have come to disdain nearly as much as the kidney. I do not state that lightly. But unlike the kidney, I actually somewhat enjoy the pathophysiology of the subject, I have just come to disdain the manner in which it is conveyed to us. For example, some of the bullshit lectures we have been fed in the past 3 weeks:
12/02 - Nutrition in Diabetes
12/05 - Nutrition Assesment
12/08 - Weight Loss
12/05 - Nutrition and Disease
12/06 - Women Nutrition
12/06 - Pediatric Nutrition

There are three main thoughts I have come to from our course direction. (1) Endocrinologists are glorified nutritionists. (2) Why am I spending $180,000 for this degree when I could get a bachelor's degree in nutrition for $60,000 (and its online!!!) (3) Why the **** are 20% of our endocrine lectures on nutrition?

Look, I know eating healthy is all puppy dogs and ice cream for your body. And the health care burden would be reduced substantially if people learned to eat better. But last I checked, med school was supposed to teach me what I needed to know to practice medicine. And there's only one thing you need to know about nutrition as a practicing physician. And that may or not begin with a "c" and end with an "-onsult nutritionist."

For comparison, we have spent 8% of our time on thyroid disorders. Ah, med school.

MSII in a nutshell.

Yes, med school is the equivalent of a sadistic 7 year old. And yes, I have a similar sort of grin on my face as med school gleefully tortures me.

New stuff coming soon. I promise. Until then, I'm focusing on keeping my humeruses (humeri?) from dislocating from their sockets.

Constructive Feedback.

Like many other medical schools throughout the land, my medical school engages in the prestigious Exam Review after each one of our sodomizations, I mean, examinations.

Its supposed to be a time for the course director and instructors to garner useful feedback on the questions and learn where they need to clarify question wording, as well as an opportunity for students to learn what questions they got wrong and why. As I am sure you can imagine, this results in a very responsible and professional environment with each party, class and course director, exchanging meaningful ideas. For example:

Course Director: "And now question 23, on the West zones of the lung..."
Class: "RABBLE RABBLE! RABBLE! RABBLE RABBLE RABBLE! RABBLE! RABBLE!"

I swear, Virchow himself could not write a sufficient test question for some members of the class. Of course, its not unexpected. Old habits die hard, and us hyper-type-A personalities have come from a long lineage of scrapping and clawing for every point back in our younger days. Most of the time you learn to let that go in medical school, but it comes out during things like... exam reviews.

I think some people are losing a good opportunity to modify there thinking process and understand WHY they came to the wrong answer. In medical school, a wrong answer is more rarely due to simply not knowing the information and much more often due to misunderstanding the information. And it would be prudent to identify what aspects of the material you misunderstanded (nuke-u-ler), and correct them before you misunderstand them in a patient. By fighting to justify your answer, you are reinforcing the information as correct in your brain.

Instead, the typical exchange goes something like this:

Instructor: "Well, B is the right answer because it is a true representation of the value of the pressures of the total respiratory system at FRC. D is wrong because it takes into account only the static dynamics of the lung."
Student X: "But, if you rearrange the words of answer D backwards, and if the question is in reference to a 82 year old African American woman with toxoplasmosis, diphtheria, and a hangnail, and if you stand on your head when you read the question... isn't D technically correct?"
Instructor: "..."

Now I can't complain too much, because my fellow classmates that smell blood on a question and really go after the course director are always successful (100% of the time, no joke) at netting me an extra couple of points on the exam. I'm more than happy to have others claw and scratch for me, because I'm a giant ball of apathy at these exam reviews.

Of course, the highlight of the exam reviews are when a certain select subset of question comes up. The Complete-and-Utter-Bullshit Question™ (CUBQ in dedication to the fact we are learning interstitial lung diseases right now). This is a question on a small minutiae of information that was either present in 2 point font at the bottom of some table somewhere in the syllabus, or the lecturer muttered the sentence under their breath during a sneeze at break, or the lecturer is playing the wonderful game of "guess what I'm thinking?" (I love that game!!!!!!!! HAHAHAHA!)

There's a certain percentage of students that will fight for every question they got wrong, but on a CUBQ its like a tsunami. It starts as a rumbling in the distance as the CUBQ is projected onto the screen. The rumbling gets louder as the course director reads the question. Then, as she unfortunately mutters the fateful phrase "Any questions?", the wave arises in front of her. Arms shoot up throughout the lecture hall, forming a wall which eventually crashes down and consumes the course director in a swirling turbine of indignation and outrage.

Ah, lecture hall. The closer I get to MS3, the more I look forward to leaving it all behind. But part of me will miss those little moments, where the "gravity" of the information being presented to us breaks way to reveal the absurdity underneath.

Revenge of the Kidney

I am a big believer in karma. Y'know, the whole "the world comes back to treat you exactly how you treat the world" jazz. So I try to keep my divisive relationships in my life to a minimum. If only I had learned from the kidney.

As has been well documented in the past, I have a hate-hate relationship with the kidney that extends all the way back to high school. When we sludged through renal physiology last spring, it was hands down the worst 2 weeks of first year (well, besides my shotgun wedding with biochemistry). I celebrated being done with the kidney. Reveled in it. May or may not have even done a happy dance in front of the mirror in just my boxers as Rick Roll blasted in the background.

Cue 4 weeks ago. MedZag's cruising along in his MS2 corvette down I5 after finishing up the first exam of the year, conveniently on cardiovascular stuff (my favorite organ system). I'm getting ready for the coming week and glance at my syllabus and the lights go out and the clock flashes over to 3:33AM as my eyes fix on Wednesday's lecture: Review of Renal Physiology. The kidney... was back.

Since then, I've suffered through such wonderful subjects as ECF Content/Volume Disorders Part I & II, Total Body Fluid H2O/Osmolality Disorders, K+ Homeostasis, Pathophysiology of Hypertension, Syndromes of Renal Disease, Evaluation of Renal Function, Renal Stone Disease, Acute Kidney Injury, Tubulointerstitial Diseases, Pathophysiology of Chronic Kidney Disease, Glomerular Disease, Acid-Base Review, Metabolic Alkalosis, Renal Tubular Acidosis and Metabolic Acidosis, Proteinuria & Nephrotic Syndrome, and Diabetic Nephropathy. There's been PBL sessions. Pathology labs. Tears.

It's bad enough that I have had to study the kidney all day long for the past month, but the kidney is not content with that. No, the kidney wants to leave me huddled and whimpering in the corner, drooling all over my chest and referring to myself as George Costanza. Yes, the kidney has also successfully invaded my dreams.

I had a dream where I was examining a path slide trying to identify if it was IgA nephropathy. A dream where I was examining a patient for rear flank pain to rule out acute pyelonephritis. A dream where I was counseling a patient in the ED on how lupus can lead to a rapidly progressing glomerulonephritis. I had a dream where I was eating a burrito and all the pinto beans had pelvises and tiny ureters.

I think I can now empathize with the chick from Exorcist: The Beginning. I wonder if renal exorcism is something they teach you in nephrology fellowship.

"Oh, You Mean Like Grey's Anatomy!"

It's often difficult to understand the culture of medicine unless you are in the middle of it. So when I talk to non-medical friends about my life and times in medical school, they draw upon the best thing they know about what I am going through.

Watching Grey's Anatomy.

Inevitably, if a story I am telling or an experience I am describing even vaguely resembles something from the television show, I get the line that makes all med students cringe: "Oh, you mean like on Grey's!" It makes sense of course. If I talked to a person who was in a traveling circus, most of my ability to relate to their life would come from watching Dumbo as a kid.

Now any med student/intern/resident/attending can tell you medicine is very much NOT like Grey's Anatomy. It's at very least half the boobs and half the libido. Which is why my interest was piqued when ABC showed trailers for their new show "Hopkins," which was billed as the "real life Grey's Anatomy."

You can watch the first episode here. I was understandably skeptical when I cracked a beer and went to watch it, since real medicine makes for horrible TV. It's a lot of boring, mundane, and paperwork, punctuated by rare moments of shit you just can't make up. Overall, I came away pleasantly surprised with the show so far. It's refreshing to see a show that humanizes doctors and the scenarios they crafted were very real. And anything that gives the general public a better view of how ridiculous physicians' lives can be sometimes is definitely a step in the right direction.

Of course, the show is partially, by its own nature, a visual and verbal fellating of the John Hopkins institution, but the Hopkins worship wasn't too bad.

Anyways, it's a 6 part series so we'll see by the end whether the show has degenerated into ER with bad actors, but so far, so good ABC. So far, so good.

The Macula Densa and Hollywood Socialites

They say in medicine everyone has their favorite organ. I think that's true (mine's the heart). Even my preceptor, who as an oncologist deals every day with a multi-system approach in her practice, didn't even have to think about hers and rattled off the thymus right after I asked. The human body is a beautiful and awe inspiring thing, and everyone eventually finds some particular facet especially elegant and thought provoking. Personally, I love the heart for its power and its simplicity - the way it utilizes electrical and fluid dynamic principles to amazingly fine tune such a critical and demanding aspect of our daily functioning as circulation. The dramatic way disease manifests itself when things go wrong. The way, in a congenitally deformed heart, things can go from horribly awry to just fine within minutes by simply moving some pipes (vessels) around and taping (suturing) everything in place.

But I'd like to counter that point with another point. Everyone also finds an organ they hate.

Mine's the kidney.

Now I am a very fun loving and agreeable guy. I have a great sense of humor and make an easy friend. So I don't throw around the word "hate" very often. I have only used the word hate in a few sorts of circumstances in my life. I hate Paris Hilton. I hate steamed squash. I hate the Santa Clara Broncos men's basketball team (sorry guys). I hate people who try to merge onto I-5 at 35mph.

And I hate the kidney. I have since the very first day I attempted to learn about it, back in high school. I hated studying it for the MCAT. I hated questions about it on said MCAT. I hated it in anatomy. In histology. In biochemistry. In physiology.
Needless to say, we're studying the kidney right now, which puts my effective motivation to study at about... 0%. My dreams are haunted by podocytes, GFR, aquaporins, and that douchebag Henle.

Why do I hate the kidney, you ask? Well, like anything involving hate in this world, I don't really have a good reason. It's a completely irrational and unfounded hate. Maybe because it makes pee. Maybe because its involved in the renin/angiotensin system (does anyone actually enjoy learning about that?). I can appreciate how important the kidney is. I can appreciate what it does is impressive. But its not fun or exciting.

One day, I may have it in my heart to forgive the kidney. Make up with it. We can be friends. But not today. Today, and for the next two weeks, you will officially be number one of my hate list, Kidney. Lock your doors.

Charlotte's Web

They say if you want to go into surgery you have to love the OR. I've always said yeah... that makes sense. You don't become a professional baseball player if you're allergic to grass.

Which brings me to one of the most disconcerting experiences of my life. From a very young age, I was fascinated by surgery. I watched operations on the Discovery Health Channel, the UW Medical Channel (which conveniently got pumped through the cable into my dorm room in college!). I've always envisioned myself as a surgeon. Told people I wanted to be a surgeon. People always told me I looked and acted like a surgeon. Hell even my Meyers-Briggs test matched me as a best fit into... surgery. Which brings me to my first OR experience in medical school.

After the initial thrill and the incredible sight of the surgeons disassembling someone's body (dramatic embellishment) and the OH MY GOD I'M IN SURGERY! ... I was bored. I'm almost ashamed to type it, but I was. My legs ached from standing, my goggles kept fogging up, and I couldn't follow what was going on. It was horrible.

The good news: things got better. The surgeons let me do a couple menial things a few times, which helped keep my attention better. But it still felt boring. And it scared me, because I almost felt like my visions of my future self were slipping away, and needless to say that was a bit frightening.

At the beginning of our Systems Processes and Homeostasis block, we got to sign up for a variety of labs which helped reinforce a variety of the concepts we were taught in class. One of the labs was a controversial lab where we worked with anesthetized live pigs, learned how to put in central lines, and observed various effects of the cardiovascular system with some manipulation.

I signed up for it, mainly because it sounded like a cool experience. I arrived in the lab this week and found our team's pig on the table, quietly unconscious and on a ventilator. Our team divvied up tasks and the task of cutting into and exposing the internal jugular vein in order to insert the central venous line landed on me (with a little bit of coaxing by myself).

Now, I've been through 12 weeks of anatomy and dissected and studied the entire human body (which was equally thrilling and boring). Any medical student can attest to the fact that working on a cadaver is both an exciting and frustrating experience. Things adhere to each other, vessels and nerves snap if you don't meticulously search them out beforehand.

With that in mind, I made my very first incision into live tissue. Unlike preserved tissue, the scalpel glided through the dermis as smooth as silk. The capillary beds bled then closed off as the body's clotting mechanisms kicked in. I found the fascial layer beneath the dermis and slowly dissected to open the incision. Unlike in a human, where the jugular is conveniently located in the easily exposed neck, in a pig it is buried down beneath layers of muscle and connective tissue. I delve deeper, finding an experience completely contrary to that of anatomy.

And it all clicked. I saw the thyroid gland, sitting with its glistening arteries wrapping themselves around the enclosed clusters of thyroglobulin. I saw the recurrent laryngeal nerve looping back up supply CNS control. I found the carotid, briskly pulsing with the powerful pressures of the heart. The vagus running down along as its mate to its destination on the heart. And I found the jugular, slowly pulling it out of its enclosing carotid sheath.

I finally understand and appreciate surgery. The elegance of it, the concentration needed during it. The care and the meticulous nature of it. I can understand why it can seem boring if you're not locked into the moment of it, but when you're involved in it, when you're focused so intensely on what you're doing, focused so intensely on what you're planning next, its like being in 'the zone.' If I end up in surgery (and I'm keeping an open mind throughout medical school) I think this will be the experience that I can look back and point to that sold me on it. Which is funny. Because if that's the case, I didn't decide on surgery because of some dramatic and amazing experience in the OR with a human. It will have been because of a pig.

Jesus, my future professional career can theoretically now be traced all the way back to Babe. But you know what, I think I'm cool with that. Word pig, ya did good.

BTW... Props to the 480, Arizona. The land of desert, desert, concrete, and more desert. If I was a rattlesnake, or dating a professional ice skater, I'd live there.